Healthcare Provider Details

I. General information

NPI: 1336857317
Provider Name (Legal Business Name): OWOSSO DENTAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E WILLIAMS ST
OWOSSO MI
48867-2360
US

IV. Provider business mailing address

109 E WILLIAMS ST
OWOSSO MI
48867-2360
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-6118
  • Fax: 989-729-9588
Mailing address:
  • Phone: 989-723-6118
  • Fax: 989-729-9588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANA L KONG
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 989-723-6118